Early Spot Urinary Sodium–Guided Diuretic Protocol in Acute Decompensated Heart Failure: Feasibility in an Indian Tertiary Hospital

Abstract

Background: Management of fluid overload in acute decompensated heart failure is frequently complicated by diuretic resistance. Traditional indicators such as weight and fluid balance, may delay identification of inadequate therapeutic response. The measurement of spot urinary sodium two hours following initial administration of intravenous loop diuretic offers an early, objective marker to guide therapeutic interventions. Although this approach is supported internationally, data from India remain limited. This study assessed the feasibility of implementing 2-hour UNa-guided diuretic escalation protocol in routine ADHF care and examined its effects on decongestion and safety in patients with ADHF.

Methods: We conducted a single-center, pragmatic pre–post pilot study involving adults admitted with acute decompensated heart failure who required intravenous loop diuretics. During intervention phase, urinary sodium was measured two hours after administration. If UNa was less than 50 mmol/L or urine output was below 100–150 mL/h, diuretic therapy was intensified by either doubling the loop diuretic dose or adding thiazide diuretic. The primary outcome assessed was 24-hour natriuresis, while secondary outcomes included diuretic efficiency, time to decongestion, length of hospital stay, and 30-day readmission rates. Baseline and intervention phases were compared using standard statistical tests. Safety outcomes were evaluated in terms of renal function, electrolyte levels, and blood pressure.

Results: A total of 160 patients were enrolled in study, comprising 80 in baseline group and 80 in intervention group. Protocol adherence exceeded 85%, and the laboratory turnaround time consistently met the 2-hour target. Feedback from staff confirmed feasibility of integrating the protocol into routine care. Preliminary analyses indicate improved natriuresis trends without significant safety concerns, and complete results are currently being finalized.

Conclusions: A 2-hour UNa-guided diuretic protocol is feasible in both Indian ward and ICU settings. This simple and cost-effective approach offers early feedback, enables timely escalation, holds potential to enhance management of ADHF.